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Inside South Carolina’s nursing crisis

By Will Moredock

South Carolina’s Nursing Crisis

By Will Moredock

The day starts early for Misty Deason in the Medical ICU ward at MUSC Hospital. She typically has two patients to care for in her 12-hour shift, but at 7 a.m. there is only one. The patient in Room 9, a 57-year-old woman, died from complications of cancer, at 6 a.m. The family is still with the body in the closed room.

Deason’s priority now is Patient 10, a 61-year-old woman with a history of myeloma. The disease knocked her white blood count down and wrecked her immune system, resulting in pneumonia. She is now on a ventilator, fighting for her life. Behind her bed is a battery of IV pumps and electronic monitors, reporting her body functions, her respirator and kidney output. Deason must make a full assessment of her surviving patient at the beginning of her shift. But she is not through with Patient 9. She notifies the hospital morgue to remove the body, then pulls together the large volume of paperwork on the deceased patient and prepares it for the records department.

There are supposed to be eight nurses on the floor to staff the 13 MICU rooms. Today there are only seven, so Charge Nurse Terry Connor will take a patient with renal failure, in addition to her regular duties overseeing and assisting the other nurses. Another nurse will take a third patient to fill the gap. Short staffing is business as usual in the MICU and nobody seems to give it a second thought.

The Nursing Shortfall

As anyone who has stayed in a hospital lately can probably tell you, there is a nursing shortage. It touches every corner of the national healthcare system and South Carolina is no exception. Nationwide, 75 percent of all hospital vacancies are for registered nurses. According to the Bureau of Labor Statistics, there will be a shortage of 1 million nurses in 2010.

“When you come into a hospital, doctors will see you for ten minutes a day,” said Dr. Gail Stuart, dean of the Medical University of South Carolina College of Nursing. “Nurses are the ones who keep patients alive.”

There are currently about 32,300 registered nurses working in the state, Stuart said. The shortfall is anticipated to peak between 2015 and 2020, with a dearth of some 15,000 nurses – or about 18 percent of the needed workforce. South Carolina currently ranks 42nd in the ratio of nurses to general population.

The shortage is the result of a perfect storm of circumstances, all of which were foreseen long ago but none of which have been addressed on a national scale. First, there is the glut of aging baby boomers, which will soon be pouring into the nation’s retirement homes and ICUs. Their conditions will be more complex and more demanding than the conditions of a younger population.

Then there is the nursing workforce itself, which is also aging. Close to 70 percent of South Carolina’s nurses are over 40. Thirty-three percent are over 50.

There is an irony in the nursing shortage, Stuart said. “We used to have a shortage of students. Now we have a shortage of faculty.” A generation ago, women – who still make up the vast majority of the nurse workforce – started leaving the field to go into business, technology and other areas once largely closed to them. As a result, nursing schools began to scale back; Duke University closed its baccalaureate program altogether. In the 1990s women began to hit the glass ceiling in their new fields and started coming back into nursing, but things had changed by then.

Today qualified candidates are lining up at MUSC College of Nursing and other nursing schools in the state. Yet the Southern Regional Education Board reports that 1,100 qualified students were turned away from nursing programs in South Carolina in 2005, due to lack of faculty. Faculty shortage has become the primary bottleneck to the training of more nurses in the state. And until the state increases faculty pay, that will remain a problem.

To teach nursing a faculty member must have at least a Master’s degree in the field. While the pay for clinical nurses has stayed competitive, it has stagnated for nursing faculty. The American Association of Colleges of Nursing reports that nursing faculty are paid as much as $30,000 less than clinical nurses with comparable education.

But the nursing shortage is about more than the absolute number of RNs. It’s about the kind of RNs, Stuart said. There are 25 schools in the state with nursing programs. Most of those are two-year technical college programs, offering Associate degrees. Today, 75 percent of nurses in the state have Associate degrees, yet national accrediting agencies recommend that no more than 33 percent of the work force should be associate nurses. The rest should have baccalaureate degrees or more. “In other words,” Stuart said, “we’re going in the wrong direction.”

The nursing shortage in South Carolina is about to get worse, the result of the state’s disjointed healthcare system. When a hospital wants to expand, it must get certification from the Department of Health and Environmental Control (DHEC). But DHEC doesn’t engage with the nursing community to determine availability of nurses to staff the new beds. More than 400 new hospital beds are scheduled to come online in the next two years. No one has asked where the nurses will come from.

In fact, 40 percent of South Carolina’s nurses come from out of state. To cover the RN vacancy rates in 2004, South Carolina hospitals spent over $77 million on agency and traveling nurses to provide adequate patient care.

The nursing shortage is one of those largely invisible problems that people – especially hospital administrators – don’t talk about for fear of scaring people away, Stuart said.

“We know this is a problem,” she said. “When does it become a crisis? You don’t know it’s a crisis until you go into a hospital and encounter a serious staffing shortage.”

A crucial role

The nursing shortage has led to some startling discoveries in the way nurses affect patient outcomes and the American healthcare system.

Having more nurses on hospital units is linked with better hospital outcomes, according to Medical Guidelines & Outcomes. The New England Journal of Medicine says that more hours of nursing care are associated with better outcomes for hospitalized patients. And The Journal of the American Medical Association reports that units staffed by nurses with baccalaureate of higher degrees had lower patient mortality. Other studies show that 24 percent of patient injuries and deaths are due to low levels of nursing staff.

These studies prove that quality nursing care is critical to creating and maintaining a quality healthcare system, Stuart said. But there are serious barriers to attracting and keeping nurses in the field. These include the outdated perception of nurses as hospital “go-fers” and a traditional antagonism between nurses and doctors, which nurse Aubrey Wade referred to in the Feb. 9, 2006, issue of Synapse, when she wrote of “the stereotypical patronizing attitude from doctors to nurses, the condescending dismissal that can bother some nurses so much that they must leave the clinical environment to preserve their self-respect.” These images are bound up in the fact that 90 percent of nurses are still women and many men seem uncomfortable taking on this traditional distaff role, even as the genders have evened out at 50-50 in med schools.

Yet there are strong incentives for entering the nursing profession, including flexible schedules and a wide variety of fields in which to practice. The image of nurses is enhanced by the high level of training they receive and the high-tech roles they play in the modern healthcare system. And the pay is good – very good, according to Stuart. Entry level salary for a baccalaureate nurse is about $45,000. A master of nursing will start at about $75,000. A doctor of nursing can make more than $115,000.
Dr. Winnie Hennessey is a freshly minted Ph.D. nurse who teaches a class in Palliative and Supportive Care at MUSC College of Nursing. On a recent morning she instructed a class of rapt baccalaureate students in the art of helping the terminally ill cross the line between life and death with dignity and peace. Her manner was warm and even humorous, but the business at hand was deadly serious, as she discussed a dizzying array of symptoms, conditions, medications, procedures.

“There’s a physiology associated with dying, like there is a physiology associated with being born,” she said. “It takes nine months of pregnancy to get born. It takes three to six months to die.”

There were 41 students in this advanced class.

Hennessey is a New York City native who has been in the nursing field more than 30 years. She got her Bachelor’s degree in nursing in 1979, her master’s in 1997 and her doctorate at MUSC last fall. Her curriculum vitae runs more than ten pages.
“I am, by nature, more of a global thinker,” she said in a telephone interview. “Caring for patients is more than just ordering a drug. It’s applying what you know respective of who they are and the way they live.”

Her “global thinking” comes from a career that has spanned the continent and placed her in such diverse fields as cardiology, digestive disease and surgical intensive care.

Her name is on more than a dozen journal articles and other publications. Now she is training the next generation of nurses who will face the tidal wave of aging baby boomers.

A MEANS FOR ECONOMIC GROWTH IN S.C.

The director of the Medical ICU, Dr. Alice Boylan, makes her morning rounds with a clutch of residents and interns following on her heals like ducklings. The morgue has removed the body from Room 9 on a specially cloaked gurney which conceals its cargo. Now Misty Deason assists an orderly in stripping the bed, turning off monitors and disposing of used IV tubes, bags and other containers. Time is critical. The new Patient 9 will be arriving soon.

She sends the old Patient 9’s paperwork to the records department and stops to consult the pharmacist on medications for Patient 10. She makes further notes, then hooks up the patient to another bag of antibiotics. “It’s just endless paperwork,” she says. But she loves what she does. And she says, “I love my patients.”

Recruiting and training nurses is about more than healthcare. It’s about economic progress in South Carolina, and Gail Stuart never misses an opportunity to make that point.

“These economic benefits are felt at each level of the economy, from the individual consumer through the corporate offices. Specifically, companies interested in potentially relocating to this state carefully consider the quality of healthcare available to their employees. The nursing shortage has a negative impact on the quality of healthcare available in this state and thus may even turn away potential industries and investors.”

Stuart doesn’t just talk – she acts. In 2003 she organized the South Carolina Nursing Collaborative – a group of six hospitals and MUSC – with the purpose of hiring more faculty and increasing class size. So far, she has raised $4 million in state and private funding, allowing the college to double the number of baccalaureate nurses it graduates each year, from 50 to 100.

Perhaps more important is the online academic program MUSC College of Nursing initiated four years ago. The program allows faculty to deliver their nursing curriculum in a cost-effective manner to offsite students throughout the state. The online program includes assigned readings, podcast lectures and films, Stuart said. “There is no passive participation in this learning process. Every student must respond to the technology to be a part of the process.”

Starting with only 20 students in 2003, the online curriculum trained 60 nurses last year. More recently, the college made its doctoral program available online. Today the South Carolina Hospital Association is lobbying the General Assembly with a sophisticated program called One Voice/One Plan. The goal is to convince the Legislature to hire as many as 66 new nursing faculty positions statewide by 2010 and attract those faculty with salary enhancements. It also calls for new scholarships, loans and grants for qualified nursing students and an Office of Healthcare Workforce Data and Research, a critical tool in anticipating healthcare needs and creating policy in South Carolina.

The health of millions of South Carolinians depends on how the General Assembly meets the challenge of One Voice/One Plan.

The health of the new patient who has been wheeled into section 9 is precarious. Since getting his new IV catheter inserted his blood pressure has stabilized and Deason took the chance to go downstairs and get some lunch. Other nurses covered for her, of course, as she has covered for them to take a break. Now she is back, checking Patient 9’s feeding tubes and the residuals in his stomach.

She is interrupted by a beeping sound from one of Patient 10’s monitors. She responds by aspirating the air out of the patient’s ventilator pump and the problem is solved.

“This is not a sexy job,” she says, as the clock ticks down the twelfth hour of her shift. “‘Gray’s Anatomy’ is sexy, but they will never do a TV show about nurses…. People think that nurses just deliver pills and give baths, but it’s nothing like that. This is not a TV show. The doctors don’t do everything. We have a lot of autonomy in recommending and acting in an emergency…. It’s a very satisfying job.”

Was it a good day?

“It’s always a good day if both of your patients are alive at the end of your shift.”

talkback@columbiacitypaper.com

Read more by Will Moredock in The Good Fight